As Professor Howard outlines in his Foreword, audit is an essential activity for all psychiatrists and will need to be evidenced for revalidation and by trainees in their Annual Review of Competence Progression (ARCP). This book aims to help ease this process by offering tried and tested recipes for conducting audits in clinical services. All the audits in this book have been undertaken by the authors but not all had been repeated to complete the audit cycle at the time of publication. While we have endeavoured to include a range of audit topics from all the specialties of psychiatry, there are some areas that we have not been able to include, as we wanted to include only audits that had been done in ‘real life’ and were reliant on the submissions from our contributors to achieve this. We would like to thank all those who have contributed audits to this book, to whom we are very grateful. We hope that readers of this book will benefit from their first-hand experiences.

In this section, each step in the completion of an audit is described in detail. As mentioned in the previous section, audit is conventionally described as a cycle. After completing each step of the audit process, the cycle should be repeated. This is to assess whether recommendations have been implemented and standards are now being met (or any other positive change can be recorded). As this process is ongoing, some authors describe the audit as a spiral rather than a cycle (Vasanthakumar & Brown, 1992) The re-audit is frequently omitted in clinical practice, especially where there is a high turnover of junior staff, as they are the most likely people to perform audits.

Although four general stages in the audit cycle were described in the previous section (Fig. 1, p. 2), there are more specific steps. In this section the audit cycle is broken into 11 steps. Not every step will be applicable to every audit, and some of the suggestions within this guide are just ‘nice to haves’:

1. 1 Choose a topic

2. 2 Consider forming a multidisciplinary team

3. 3 Review the literature

4. 4 Set standards

5. 5 Choose an audit design

6. 6 Collect the data

7. 7 Analyse the data

8. 8 Make conclusions and recommendations

9. 9 Disseminate results

10. 10 Implement change

11. 11 Re-audit

Step 1. Choose a topic

Consider which area to audit

In 1966 Donabedian described three areas which can be audited in the healthcare setting: the facilities available (structure), what happens there (process) and the result for the patient (outcome). All audits are likely to fall into at least one of these categories; some may fall into two or all three categories.

The dimensions of quality of care that can be assessed in mental health audits could include access to services, relevance to need, effectiveness, equity, social acceptability and efficiency (Maxwell, 1984; Hatton & Renvoize, 1991). Trusts are now required to meet the standards of quality and safety that are set out in two pieces of legislation: the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. There are 28 specific regulations, which cover the care and welfare of people who use services, infection control, the safety of premises and consent to treatment.

Acute confusion: recognition

Antenatal and postnatal mental health

Attention-deficit hyperactivity disorder: provision of information

Bipolar depression: treatment

Bipolar disorder: management

Bipolar disorder: shared decision-making

Bipolar disorder: treatment

Chronic fatigue syndrome

Dementia: driving

Dementia: end-of-life care

Dementia: investigations

Depression: management in children and young people

Eating disorders: management

Epilepsy: management

Opiate dependence and pregnancy

Schizophrenia: family interventions

Schizophrenia: management

Schizophrenia: occupational achievements

Self-harm: assessment

Self-harm: assessment in children

Setting

This audit is appropriate for all psychiatric services but may be more relevant to in-patient units.

Background

Incorporating evidence-based infection prevention and control advice into routine clinical care is believed to be important in reducing the incidence of preventable healthcare-associated infections.

Standards

There are numerous standards relating to infection control to which mental health trusts have an obligation to adhere (including National Institute for Health and Clinical Excellence, 2003; Infection Control Nurses Association, 2005; Department of Health, 2006).

Standards most relevant to the mental health trust can be selected for the audit process. Either single recommendations or combinations can be used. Four domains of care were selected for audit:

ᐅ Sharps. Sharps, needle-stick injuries, bites and splashes involving blood or other body fluids are managed in a way that reduces the risk of injury or infection (26 possible individual standards).

ᐅ Hand hygiene. Hands will be decontaminated correctly and in a timely manner using a cleansing agent, to reduce risk of cross-infection (25 possible individual standards).

ᐅ Personal protective equipment. Personal protective equipment is available and is used appropriately to reduce the risk of cross-infection (21 possible individual standards).

ᐅ Specimen handling. Specimens are handled in a way that negates the risk of cross-infection to all staff (18 possible individual standards).

The standards should be met in all areas in all domains.

Method

Data collection

The data related largely to the presence or absence of equipment on the ward. A tick-box data-collection sheet covering all relevant domains was used. This sheet contained the four main domain headings and the individual standards within each domain. For each standard the auditor indicated whether the standard was met (Yes / No / Not applicable).

Data analysis

Data were collated using spreadsheet software. Compliance with the standards was calculated for:

ᐅ the four domains described in the standards above

ᐅ the individual standards within each domain

ᐅ each trust, locality or team.

Resources required

People

This audit was coordinated by an audit facilitator; at each site at least one person collected data.

Time

Each individual required at least 1 hour to collect the data on the local ward or unit, but this depends on the size of the unit.

Alcohol withdrawal: management

Anticholinesterase inhibitors: monitoring of cardiac side-effects

Anticholinesterase inhibitors: prescribing

Antimuscarinic medications

Antipsychotics: combined and high dose

Antipsychotics: prescribing

Antipsychotics: use in dementia

Attention-deficit hyperactivity disorder: prescribing

Atypical antipsychotics: monitoring

Behavioural problems in adults with intellectual disabilities: medication management

Benzodiazepines in old age psychiatry

Covert administration of medication

Depot antipsychotics: side-effects

Diazepam as rescue medication in epilepsy

Electroconvulsive therapy: facilities

Electroconvulsive therapy: indications

Hypnotics

Lithium: monitoring

Medicines reconciliation

Mood stabilisers: monitoring

Nurses’ administration of medication

Prescribing: British National Formulary limits

Prescribing: Mental Capacity Act

Prescribing: p.r.n. medication

Prescription charts

Psychological therapies

Psychotherapy re-referrals

Psychotropic prescriptions in dual diagnosis

Rapid tranquillisation

Early intervention teams

Emergency department: attendance

Information for in-patients on their rights

Interpreters

Liaison psychiatry: response time to referrals

Multi-agency working

Personal searches

Prison equivalence

Prison-to-hospital transfers

Seven-day follow-up

Substance misuse: the Treatment Outcomes Profile

Transition from ‘choice’ to ‘partnership’ in the Choice and Partnership Approach

Transition planning in attention-deficity hyperactivity disorder

Violent incidents: management

Waiting times

Setting

This audit was performed in a child and adolescent mental health service (CAMHS), but can be adapted to any service where there is frequent interaction with non-mental health organisations such as social services or education.

Background

Multidisciplinary approaches to complex cases referred to CAMHS are both mandated and necessary, but multidisciplinary working is time-consuming and resource intensive, especially where processes are not functioning optimally. CAMHSs are envisioned as providing a mix of direct and indirect (consultation and liaison) services. The approach requires communication between agencies with different backgrounds, roles and working practices. The aim of this audit was to assess the use and outcome of time allocated for this purpose.

Standards

The standards were derived from principles laid down in the National Service Framework (Department of Health, 2004), Every Child Matters (Chief Secretary to the Treasury, 2003) and Good Medical Practice (General Medical Council, 2006):

ᐅ Referral pathways, the organisational process and the aims of the consultation should be clear.

ᐅ Communication, discussion and decisions should be documented and accessible after the consultation.

ᐅ Attendance should be documented and named workers should be made responsible for recommended actions.

Method

Data collection

The process used to arrange consultations with non-mental health organisations was identified. Notes from those consultations were located to determine the presence of the following:

ᐅ the attendees and their designations

ᐅ the discussion, decision and action plans.

Data analysis

The percentages of cases in which information was clearly documented according to the above standards were calculated.

Resources required

People

This audit can be carried out by a single person of any discipline, although in large services more than one person may be required.

Time

The time required will depend on the size of the sample and the process in place locally. In the first stage of the audit, data collection took around 20 hours for 115 potential cases, from which only 12 relevant cases were found. In the second stage only 4 hours was required for 28 potential cases, from which 14 relevant cases were found, with two auditors in each case.